Letter to the Editor: Is lifestyle modification effective for individuals with high fibrosis-4 index without an additional second-tier test?
Authors: Huiyul Park, Eileen L. Yoon, Mimi Kim, Sun-Hong Kwon, Dae Won Jun, Hye-Lin Kim
Journal: Hepatology (2023)

To the editor, Screening for advanced hepatic fibrosis in at-risk populations is a crucial issue. Vibration-controlled transient elastography and magnetic resonance elastography (MRE) are commonly recommended as second-tier noninvasive tests in most guidelines. However, they are expensive, raising questions about their cost-effectiveness in real-world practice. Sangha et al.1 concluded that MRE, despite being expensive, was cost-effective in FIB-4 high-risk groups for screening advanced hepatic fibrosis. It would be immensely valuable if the author could suggest additional data for cost-effectiveness analyses of the FIB-4 and MRE algorithms to accurately diagnose liver conditions without the need for a biopsy. Such data would be highly beneficial for informing policy decisions. First, Sangha et al compared the vibration-controlled transient elastography, MRE, MRE+Biopsy, and vibration-controlled transient elastography+MRE+Biopsy groups. Given the 80% prevalence of advanced hepatic fibrosis in individuals with FIB-4 > 2.6, implementation of an intensive lifestyle intervention (ILI) alone, without additional second-tier screening tests, may be considered in them. An evaluation of the efficacy of ILIs alone in individuals with FIB-4 scores > 2.6 is crucial to identify the optimal approach. Second, the Markov model utilized in Sangha et al's study assumed a starting age of 50 years and a lifetime horizon. It is generally recommended to choose a sufficiently long assessment period in cost-effectiveness analyses to identify important clinical outcomes; however, the study's base-case analysis estimated quality-adjusted life-years (QALYs) ranging from 49.88 to 51.59 in each alternative. These results suggest that the study population would live for ≥100 years. Given that 80% of the target population had advanced hepatic fibrosis, their life-years were likely overestimated. The simulation yielded 49.88 QALYs for a patient at F1–F2 health state, who had survived for 52.5 years (utility of 0.95 as per Table 3; 52.5 y * 0.95 = 49.88 QALYs), without progression to unfavorable conditions. Similarly, for a patient with an F3 health state, 54.2 years of life equated to 49.88 QALYs. Thus, QALYs of 49.88–51.59 indicated that a 50-year-old patient with advanced hepatic fibrosis could live for >100 years on average. Third, the authors assumed that all patients adhered to the ILIs, and the rate of fibrosis regression (19%) in the treated group was used. However, it was unclear whether the regression rate (0.05–0.06) was applied only to the treatment group or if it was a spontaneous rate that appeared regardless of treatment. It would be beneficial if the process of calculating the ILI effect as an annual probability was explained in more detail. Patients with advanced hepatic fibrosis are at a significantly increased risk for cardiovascular mortality. Therefore, when conducting a cost-effectiveness evaluation, it is important to consider the impact of ILI on the liver and cardiovascular disease burden, which are major complications. This dual effect underscores the potential value of the interventions aimed at improving the overall health and well-being of patients with advanced hepatic fibrosis.